Internal Medicine Program Directors Research Articles

Management of the Electronic Health Record Inbox: Results From a National Survey of Internal Medicine Program Directors.

Background Internal medicine (IM) resident physicians spend a considerable amount of time managing their inbox as part of their longitudinal continuity clinic experience. There are no standardized guidelines for how programs should train, monitor, or supervise residents in this type of patient care. Objective To understand how IM residency programs educate, monitor, and supervise resident electronic health record (EHR) inbox management as part of their longitudinal continuity clinic and determine whether patient safety events have occurred due to EHR inbox-related patient care decisions made by unsupervised resident physicians. Methods In August 2021, 439 program directors at accredited US IM residency programs who were members of the Association of Program Directors in Internal Medicine (APDIM) were asked 12 questions developed by the study authors and APDIM survey committee members regarding resident EHR inbox management as part of the annual APDIM survey. Results Two hundred and sixty-seven (61%) PDs responded. The majority (224 of 267, 84%) of programs provided guidelines for expected message response times; less than half (115, 43%) monitored timeliness metrics. Only half (135; 51%) of programs required faculty supervision of inbox messages for all residents; 28% (76) did not require supervision for any residents. Twenty-one percent of PDs (56) reported awareness of a patient safety event occurring due to an unsupervised resident inbox-related patient care decision. Conclusions Substantial variability exists in how IM residency programs train, monitor, supervise, and provide coverage for resident inbox work. Program directors are aware of patient safety events resulting from unsupervised resident inbox management.

Updating the Military Unique Curriculum for a Ready Medical Force.

Previous conflicts have demonstrated the impact of physician readiness on early battlefield mortality rates. To prepare for the lethal nature of today's threat environment and the rapid speed with which conflict develops, our medical force needs to sustain a high level of readiness in order to be ready to "fight tonight." Previous approaches that have relied on on-the-job training, just-in-time predeployment training, or follow-on courses after residency are unlikely to satisfy these readiness requirements. Sustaining the successes in battlefield care achieved in Iraq and Afghanistan requires the introduction of effective combat casualty care earlier and more often in physician training. This needs assessment seeks to better understand the requirements, challenges, and opportunities to include the Military Unique Curriculum (MUC) during graduate medical education. This needs assessment used a multifaceted methodology. First, a literature review was performed to assess how Military Unique Curricula have evolved since their initial conception in 1988. Next, to determine their current state, a needs-based assessment survey was designed for trainees and program directors (PDs), each consisting of 18 questions with a mixture of multiple choice, ranking, Likert scale, and free-text questions. Cognitive interviewing and expert review were employed to refine the survey before distribution. The Housestaff Survey was administered using an online format and deployed to Internal Medicine trainees at the Walter Reed National Military Medical Center (WRNMMC). The Program Director Survey was sent to all Army and Navy Internal Medicine Program Directors. This project was deemed to not meet the definition of research in accordance with 32 Code of Federal Regulation 219.102 and Department of Defense Instruction 3216.02 and was therefore registered with the WRNMMC Quality Management Division. Out of 64 Walter Reed Internal Medicine trainees who received the survey, 32 responses were received. Seven of nine PDs completed their survey. Only 12.5% of trainees felt significantly confident that they would be adequately prepared for a combat deployment upon graduation from residency with the current curriculum. Similarly, only 14.29% of PDs felt that no additional training was needed. A majority of trainees were not satisfied with the amount of training being received on any MUC topic. When incorporating additional training on MUC topics, respondents largely agreed that simulation and small group exercises were the most effective modalities to employ, with greater than 50% of both trainees and PDs rating these as most or second most preferred among seven options. Additionally, there was a consensus that training should be integrated into the existing curriculum/rotations as much as possible. Current Military Unique Curricula do not meet the expected requirements of future battlefields. Several solutions to incorporate more robust military unique training without creating any significant additional time burdens for trainees do exist. Despite the limitation of these results being limited to a single institution, this needs assessment provides a starting point for improvement to help ensure that we limit the impact of any "peacetime effect."

Piloting web-based structural competency modules among internal medicine residents and graduate students in public health.

Fewer than half of internal medicine program directors report any health disparities curriculum. We piloted a web-based healthcare disparities module among internal medicine (IM) residents to test effectiveness and feasibility, compared to a convenient sample of graduate students enrolled in a public health equity course. IM residents participated in an in-person session (module 1: introduction to racial and ethnic health disparities), but first, they completed a pre-module knowledge quiz. Two weeks later, they completed module 2: "unconscious associations" and a post-module knowledge quiz. For the control arm Yale School of Public Health (YSPH) students enrolled in a course on health disparities completed the pre-module knowledge quiz, module 1, and 2 as required by their course instructor. Forty-nine IM residents and 22 YSPH students completed the pre-module quiz and Module 1. The mean (SD) score out of 25 possible points for the IM residents on the pre-module quiz was 16.1/25 (2.8), and 16.6/25 (3.2) for YSPH students, with no statistically significant difference. Nineteen residents (38.8%) completed the post-module quiz with a mean score of 16.7/25 (2.2), Hedge's g =0.23, compared to 18 (81.8%) YSPH students, whose mean (SD) score was 19.5/25 (2.1), Hedge's g=1.05. YSPH students' post-module quiz average was statistically significantly higher than their pre-module test score, as well as the residents' post-module test (P < 0.001). In examining participants' responses to specific questions, we found that 51% (n = 25) of residents wrongly defined discrimination with an emphasis on attitudes and intent as opposed to actions and impact, compared to 22.7% (n = 5) YSPH students before the module, vs. 63.2% (n = 12) and 88.9% (n = 16) respectively after. After completing a healthcare disparities course, graduate students in public health saw greater gains in knowledge compared to IM residents. Residents' responses showed knowledge gaps such as understanding discrimination, and highlight growth opportunity in terms of health equity education. Furthermore, embedding health equity education in required curricular activities may be a more effective approach.

Residency Program Responses to Early COVID-19 Surges Highlight Tension as to Whether Residents Are Learners or Essential Workers.

PurposeTo quantify the extent to which internal medicine (IM) residents provided care for patients with COVID-19 and examine characteristics of residency programs with or without plans (at some point) to exclude residents from COVID-19 care during the first 6 months of the pandemic.MethodThe authors used data from a nationally representative, annually recurring survey of U.S. IM program directors (PDs) to quantify early (March–August 2020) resident participation in COVID-19 care. The survey was fielded from August to December 2020. PDs reported whether they had planned to exclude residents from COVID-19 care (i.e., PTE status). PTE status was tested for association with program and COVID-19 temporal characteristics, resident schedule accommodations, and resident COVID-19 cases.ResultsThe response rate was 61.5% (264/429). Nearly half of PDs (45.4%, 118/260) reported their program had planned at some point to exclude residents from COVID-19 care. Northeastern U.S. programs represented a smaller percentage of PTE than non-PTE programs (26.3% vs 36.6%; P = .050). PTE programs represented a higher percentage of programs with later surges than non-PTE programs (33.0% vs 13.6%, P = .048). Median percentage of residents involved in COVID-19 care was 75.0 (interquartile range [IQR]: 22.5–100.0) for PTE programs, compared with 95.0 (IQR: 60.0–100.0) for non-PTE programs (P < .001). Residents participated most in intensive care units (87.6%, 227/259) and inpatient wards (80.8%, 210/260). Accommodations did not differ by PTE status. PTE programs reported fewer resident COVID-19 cases than non-PTE programs (median percentage = 2.7 [IQR: 0.0–8.6] vs 5.1 [IQR: 1.6–10.7]; P = .011).ConclusionsIM programs varied widely in their reported plans to exclude residents from COVID-19 care during the early pandemic. A high percentage of residents provided COVID-19 care, even in PTE programs. Thus, the pandemic highlighted the tension as to whether residents are learners or employees.

Parental Leave Policies in Residency: A National Survey of Internal Medicine Program Directors

Purpose To characterize the existence, accessibility, and content of parental leave policies, as well as barriers to program-level policy implementation among internal medicine (IM) program directors (PDs) and to assess the willingness of PDs to implement a national standardized policy. Method In 2019, the Association of Program Directors in Internal Medicine conducted a survey of 422 IM PDs. Along with other content, 38 questions addressed 4 primary outcomes: parental leave policy existence, accessibility, content, and barriers. The authors compared programs with and without a program-level policy and applied qualitative content analysis to open-ended questions about barriers to policy implementation and openness to a national standard. Results The response rate was 69.4% (293/422). Of responding programs, 86% (250/290) reported a written parental leave policy with 43% (97/225) of these originating at the program level. Program-level policies, compared with policies at other levels, were more likely to address scheduling during pregnancy (38%, 36/95 vs 22%, 27/124; P = .018); peer coverage (24%, 21/89 vs 15%, 16/109; P = .037), how the duration of extended training is determined (81%, 72/89 vs 44%, 48/109; P &lt; .001), and associated pay and benefits 61%, 54/89 vs 44%, 48/109; P = .009). PDs without program-level policy reported lacking guidance to develop policy, deferring upward to institutional policies, and wishing to retain flexibility. More than half of PDs (60%, 170/282) expressed agreement that a national standard for a residency program-level parental leave policy should exist. Those not in favor cited organization equity, lack of resources, implementation challenges, loss of flexibility, and potentially disadvantaging recruitment. Conclusions While existing program-level policies included important content, most PDs reported not having them. A national standard to guide the development of program-level parental leave policies could be embraced if it provided flexibility for programs with limited resources.

Association of Women Leaders with Women Program Director and Trainee Representation Across US Academic Internal Medicine.

BackgroundWomen are underrepresented within internal medicine (IM). Whether women leaders attract women trainees is not well explored.ObjectiveTo characterize leader and trainee gender across US academic IM and to investigate the association of leader gender with trainee gender.DesignCross-sectional study.ParticipantsLeaders (chairs, chiefs, program directors (PDs)) in 2018 and trainees (residents, fellows) in 2012–2016 at medical school-affiliated IM and seven IM fellowship programs.ExposureLeadership (chair/chief and program director; and, for resident analyses, fellow) gender.Main MeasuresOur primary outcome was percent women trainees (IM residents and, separately, subspecialty fellows). We used standard statistics to describe leadership and trainee gender. We created separate multivariable linear regressions to evaluate associations of leader gender and percent women fellows with percent women IM residents. We then created separate multivariable multilevel models (site as a random effect) to evaluate associations of leader gender with percent women subspecialty fellows.Key ResultsOur cohort consisted of 940 programs. Women were 13.4% of IM chairs and <25% of chiefs in each fellowship subspecialty (cardiology: 2.6%; gastroenterology: 6.6%; pulmonary and critical care: 10.7%; nephrology: 14.4%; endocrinology: 20.6%; hematology-oncology: 23.2%; infectious diseases: 24.3%). IM PDs were 39.7% women; fellowship PDs ranged from nearly 25% (cardiology and gastroenterology) to nearly 50% (endocrinology and infectious disease) women. Having more women fellows (but not chairs or PDs) was associated with having more women residents (0.3% (95% CI: 0.2–0.5%) increase per 1% fellow increase, p<0.001); this association remained after adjustment (0.3% (0.1%, 0.4%), p=0.001). In unadjusted analyses, having a woman PD (increase of 7.7% (4.7%, 10.6%), p<0.001) or chief (increase of 8.9% (4.6%, 13.1%), p<0.001) was associated with an increase in women fellows; after adjustment, these associations were lost.ConclusionsWomen held a minority of leadership positions in academic IM. Having women leaders was not independently associated with having more women trainees.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-022-07635-w.

Making the Personal Statement "Truly Personal": Recommendations From a Qualitative Case Study of Internal Medicine Program and Associate Program Directors.

The personal statement is an integral part of a residency application but little guidance exists for medical students about what content to include. We use the framework of isomorphism, the process by which institutions model themselves after one another, to understand what internal medicine program directors (PDs) and associate program directors (APDs) recommend be included in the personal statement and how programs use personal statements in their selection of applicants to interview and rank. Semi-structured phone interviews were conducted between August and October 2020 with 13 academic PDs and APDs, who were selected for participation based on program size and geographic location. Interviews were recorded, transcribed, and coded using content analysis. Effective personal statements should be well-written, present unique information, and demonstrate fit with a residency program. PDs and APDs recommended against expressing lack of interest in a program or highlighting negative personal characteristics. PDs and APDs used personal statements to distinguish between applicants and noted that personal statements help programs form an impression of the applicant. Consensus among PDs and APDs about what personal statements should include and how they are used indicates that isomorphism influences the match process. Our study found that the personal statement is a valued part of the residency application when it includes unique attributes and reveals personal values that align with that of the program. Additionally, PDs and APDs noted that when applicants highlight their unique characteristics, it can help distinguish themselves from others.

Internal Medicine Residency Program Director Support and Burnout During the COVID-19 Pandemic: Results of a National Survey.

Burnout is common among physicians and physician leaders, including residency program directors (PDs). The effects of the COVID-19 pandemic and other stressors in 2020 on PDs is unknown. To measure the prevalence of burnout among internal medicine (IM) residency PDs 6 months into the COVID-19 pandemic. A total of 429 IM PDs, representing 83% of accredited residency programs, were surveyed from August to December 2020. Burnout, using a 2-item screening tool, and self-reported consideration of resigning in 2020, were compared to their annual prevalence since 2012 and tested for possible associations with pandemic stressors and program characteristics. The survey response rate was 61.5% (264 of 429). One-third (33.6%, 87 of 259) of PD respondents met burnout criteria, and 45.1% (110 of 244) reported considering resigning in the past year, which were within the range of preceding years. PDs who reported feeling highly supported by institutional leadership were less likely to meet burnout criteria and to have considered resigning. There were no associations between burnout or consideration of resigning and the amount of clinical time PDs spent in their roles, duration of maximum stress on programs, budget cuts to programs, or geographic region. The prevalence of burnout among PDs in fall 2020 was similar to the prevalence of burnout in pre-pandemic years despite uniquely extreme stressors. PDs' perception of being highly supported by institutional leadership was associated with lower prevalence of burnout and consideration of resigning. Perceived leadership support may be a protective factor against burnout during periods of high stress.

Characterization of Internal Medicine Chief Resident Administrative, Educational, and Clinical Experiences

The internal medicine (IM) chief residency is a position of leadership and honor common in IM programs, but the goals, responsibilities, and experiences of those who undertake it can be highly variable. Studies assessing the experience and impressions of the chief resident (CR) position from the viewpoint of the IM CRs are lacking. To describe the structure, responsibilities, and perceptions of the IM CR role across IM residency programs. A cross-sectional, simple descriptive electronic survey for current CRs was administered between April and June 2018 across US IM residency programs accredited by US Accreditation Council for Graduate Medical Education. A 2-step nonrandom sampling approach was used: first, snowball sampling was performed using the authors' professional networks, and second, the survey was sent to the Association of Program Directors in Internal Medicine (APDIM) CR listserv. Data analysis was performed from June 2020 to August 2020. Participation as a CR for an IM residency program in the 2017 to 2018 academic year. Descriptive CR personal and program characteristics and CR perceptions of administrative, clinical, and leadership experiences. Among 169 unique responses, 77 participants (46%) were female and 89 (53%) were White. The response rate was 57% (70 of 122 surveys) in the snowball sample and 12% (99 of 842 surveys) in the APDIM listserv. The 2 sampled groups were combined for analysis. Most respondents (125 CRs [74%]) were from academic or university-based programs. Common across CR responses was responsibility for administrative tasks, clinical work, and educational efforts. Most CRs (111 of 157 respondents [71%]) reported being the primary schedulers for the residency program. Clinical work differed widely across respondents. Only 70 of 156 respondents (45%) reported having an academic title associated with the CR role. CRs reported inconsistent evaluation throughout the year, with high percentages reporting never receiving feedback on teaching (34 respondents [23%]), clinical abilities (67 respondents [45%]), or leadership abilities (60 respondents [40%]). Most CRs (107 respondents [69%]) agreed that they find work as a CR fulfilling and 117 (74%) agreed they would do chief residency again. Despite its ubiquity in training programs across the US, the IM CR experience is very different across programs. Recommendations are provided to consider for improvement of the CR experience, including structured feedback opportunities, maximizing educational and clinical experiences, and standardizing policies.

The Impact of Virtual Interviews on Recruitment in Hospice and Palliative Medicine Fellowship Training

ContextThe ongoing COVID-19 pandemic has led many leaders to reassess how recruitment into the medical field is conducted. In Hospice and Palliative Medicine, many training programs are moving to virtual recruitment as a more permanent strategy. However, virtual recruitment disproportionately affects smaller training programs as well as those in smaller cities or those whose location is less well-known. ObjectivesTo assess faculty perspective regarding the value of virtual vs. face-to-face recruitment methods in a well-established program located in a mid-sized city that is lesser known than many comparable programs. MethodsAfter virtual recruitment season in 2020, we assessed our faculty regarding the process of virtual interviews. Survey items were based on results of the 2020 NRMP Internal Medicine Program Director Survey to include the most highly cited factors used to rank internal medicine applicants. Faculty was asked whether virtual or face-to-face interviews were more effective and were asked to make an overall choice between face to face and virtual recruitment formats and to explain the reason behind their decision. ResultsTwenty-three faculty received the survey and 17 completed. Although more faculty felt that in-person interviews allowed for better ability to recruit the most qualified trainees than virtual interviews, nine out of the 17 faculty chose virtual as their preferred format. ConclusionWhile acknowledging benefits that can only be achieved in-person, our faculty believe that virtual interviews for future Hospice and Palliative Medicine fellows is an effective and potentially advantageous way to recruit the future work force of Hospice and Palliative Medicine.

Hazard pay for internal medicine resident physicians during the COVID‐19 pandemic: A national survey of program directors

BackgroundHazard pay for resident physicians has been controversial in the COVID‐19 pandemic. Program director (PD) beliefs about hazard pay and the extent of provision to internal medicine (IM) residents are unknown.ObjectiveTo evaluate hazard pay provision to residents early in the COVID‐19 pandemic and pandemic and residency program characteristics associated with hazard pay.Design, Setting, and ParticipantsA nationally representative survey was conducted of 429 US/US territory‐based IM PDs from August to December 2020.Main Outcome and MeasuresHazard pay provision and PD beliefs about hazard pay were tested for association with factors related to the pandemic surge and program characteristics.ResultsResponse rate was 61.5% (264/429); 19.5% of PDs reported hazard pay provision. PD belief about hazard pay was equivocal: 33.2% agreed, 43.1% disagreed, and 23.7% were uncertain. Hazard pay occurred more commonly in the Middle‐Atlantic Census Division (including New York City) and with earlier surges and greater resident participation in COVID‐19 patient care. Hazard pay occurred more commonly where PDs supported hazard pay (74.5% vs. 22.1%, p = .018). Reasons most frequently given in support of hazard pay were essential worker status, equity, and schedule disruption. Those opposed cited professional obligation and equity.ConclusionHazard pay for IM residents early in the COVID‐19 pandemic was nominal but more commonly associated with heavily impacted institutions. Although PD beliefs were mixed, positive belief was associated with provision. The unique role of residents as both essential workers and trainees might explain our varied results. Further investigation may inform future policy, especially in times of crisis.

84. Paying for Parenthood: Misinterpretation of ABIM Leave Policies May Lead to Unnecessary Extension of ID Fellowships

BackgroundMany trainees plan pregnancy during fellowship training. A study of internal medicine program directors (PDs) demonstrated frequent misinterpretation of American Board of Internal Medicine (ABIM) leave policies when applied to parental leave. The ABIM has since attempted to clarify its leave and deficits in training policies. The primary aim of this study was to investigate how infectious disease (ID) program directors interpret the current ABIM leave policies in crafting parental leave for trainees.MethodsWe surveyed 155 ID program directors in an online, anonymous questionnaire regarding their knowledge of ABIM leave policies and application toward trainees’ leaves of absence. Results75/155 (48%) of program directors responded to the survey. Most respondents incorrectly identified the leave limits permitted by ABIM policies, and a majority mistakenly chose to extend training when a clinically competent fellow was within their allowed duration of leave.(Figure 1) Most respondents correctly identified that equal time is permitted for both birth and non-birth parent parental leave, however, reported leave durations did not reflect this equity. PDs reported the majority (60.4%) of ID trainee maternity/birth parent leaves at their programs were ≤7weeks and 4.6% were≤3 weeks, while only 7% were≥12 weeks. In contrast, 50% of paternity/non birth parent leaves were ≤3weeks and none were ≥12 weeks. (Figure 2) PDs utilize various strategies to prevent extending training for fellows taking parental leaves that exceed the limits allowed by ABIM policies, including creating “home electives,” though 34% counsel trainees to take “a shorter maternity leave.” ConclusionFellowship program directors often misinterpret ABIM leave policies, and misapply them when given example scenarios. These findings have clear implications for trainees’ family planning and may lead to shortened parental leaves and inappropriate fellowship training extensions. Disclosures All Authors: No reported disclosures

Virtual Recruitment: Experiences and Perspectives of Internal Medicine Program Directors

Virtual Recruitment: Experiences and Perspectives of Internal Medicine Program Directors

The State of Morning Report in the Current Healthcare Landscape: a National Survey of Internal Medicine Program Directors.

BackgroundCase-based Morning Report (MR) has long been the predominant educational conference in Internal Medicine (IM) residency programs. The last comprehensive survey of IM MR was in 1986. Much has changed in the healthcare landscape since 1986 that may impact MR.ObjectiveWe sought to determine the current state of MR across all US IM programs.DesignIn 2018, US IM program directors (PDs) were surveyed about the dynamics of MR at their institutions, perceived pressures, and realized changes.Key ResultsThe response rate was 70.2% (275/392). MR remains highly prevalent (97.5% of programs), although held less frequently (mean 3.9 days/week, SD 1.2), for less time (mean 49.4 min, SD 12.3), and often later in the day compared to 1986. MR attendees have changed, with more diversity of learners but less presence of educational leaders. PD presence at MR is associated with increased resident attendance (high attendance: 78% vs 61%, p=0.0062) and punctuality (strongly agree/agree: 59% vs 43%, p=0.0161). The most cited goal for MR is utilizing cases to practice clinical reasoning. Nearly 40% of PDs feel pressure to move or cancel MR; of those, 61.2% have done so, most commonly changing the timing (48.5%), reducing the length (18.4%), and reducing the number of sessions per week (11.7%). Compared to community-based and to community-based, university-affiliated programs, university-based programs have 2.9 times greater odds (95% CI: 1.3, 6.9; p = 0.0081) and 2.5 times greater odds (95% CI 1.5, 4.4; p =0.0007), respectively, of holding MR after 9 AM, and 1.8 times greater odds (95% CI: 0.8, 4.2; p = 0.1367) and 2.0 times greater odds (95% CI: 1.2, 3.5; p = 0.0117), respectively, of reporting pressure to cancel or move MR compared to their counterparts.ConclusionsWhile MR ubiquity reflects its continued perceived value, PDs have modified MR to accommodate changes in the healthcare environment. This includes reduced frequency, shorter length, and moving conferences later in the day. Additional studies are needed to understand how these changes impact learning.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-07010-1.

Why Internal Medicine Program Directors Remain in Their Positions and Are Effective and Thrive: A Qualitative Study

Medical education must be led by qualified, experienced physician-educators.1,2 Residency program directors (PDs) balance unique challenges and responsibilities that include personal and professional development of their trainees while ensuring accreditation requirement compliance.2 The Accreditation Council for Graduate Medical Education (ACGME) mandates that a single PD has the authority, accountability, and responsibility for the program and requires that PDs serve long enough to ensure program stability.

Perspectives of Internal Medicine Residency Program Directors on the Accreditation Council for Graduate Medical Education (ACGME) Diversity Standards.

To increase diversity and inclusion in graduate medical education, the Accreditation Council for Graduate Medical Education (ACGME) issued a revision to their Common Program Requirements during the 2019-2020 academic year mandating that all residency programs must have policies and practices to achieve appropriate diversity among trainees and faculty. To explore the perspectives of internal medicine program directors (PDs) and associate program directors (APDs) on the ACGME diversity standard. Qualitative study of internal medicine residency program leadership from academic and community programs across the USA. Current PDs (n = 12) and APDs (n = 8) of accredited US internal medicine residency programs. We conducted semi-structured, in-depth qualitative interviews. Data was analyzed using the constant comparative method to extract recurrent themes. Three main themes, described by participants, were identified: (1) internal medicine PDs and APDs had limited knowledge of the new Common Program Requirement relating to diversity; (2) program leaders expressed concern that the diversity standard reaches beyond the PDs' scope of influence and lack of institutional commitment to the successful implementation of diversity standards; (3) participants described narrow view of diversity and inclusion efforts focusing on recruitment strategies during the interview season. Our findings of lack of familiarity with the new diversity standards, and limited institutional investment in diversity and inclusion efforts raise a concern about successful implementation across GME programs. Nevertheless, our finding suggests that structured implementation in the form of education, guideposts, and financial allocation can alleviate some of the concerns of program leadership in meeting the new ACGME diversity standard in a meaningful way.

A comparison of orthopaedic surgery and internal\xa0medicine perceptions of USMLE Step 1 pass/fail scoring

BackgroundUnited States Medical Licensing Examination Step 1 will transition from numeric grading to pass/fail, sometime after January 2022. The aim of this study was to compare how program directors in orthopaedics and internal medicine perceive a pass/fail Step 1 will impact the residency application process.MethodsA 27-item survey was distributed through REDCap to 161 U.S. orthopaedic residency program directors and 548 U.S. internal medicine residency program directors. Program director emails were obtained from the American Medical Association’s Fellowship and Residency Electronic Interactive Database.ResultsWe received 58 (36.0%) orthopaedic and 125 (22.8%) internal medicine program director responses. The majority of both groups disagree with the change to pass/fail, and felt that the decision was not transparent. Both groups believe that the Step 2 Clinical Knowledge exam and clerkship grades will take on more importance. Compared to internal medicine PDs, orthopaedic PDs were significantly more likely to emphasize research, letters of recommendation from known faculty, Alpha Omega Alpha membership, leadership/extracurricular activities, audition elective rotations, and personal knowledge of the applicant. Both groups believe that allopathic students from less prestigious medical schools, osteopathic students, and international medical graduates will be disadvantaged. Orthopaedic and internal medicine program directors agree that medical schools should adopt a graded pre-clinical curriculum, and that there should be a cap on the number of residency applications a student can submit.ConclusionOrthopaedic and internal medicine program directors disagree with the change of Step 1 to pass/fail. They also believe that this transition will make the match process more difficult, and disadvantage students from less highly-regarded medical schools. Both groups will rely more heavily on the Step 2 clinical knowledge exam score, but orthopaedics will place more importance on research, letters of recommendation, Alpha Omega Alpha membership, leadership/extracurricular activities, personal knowledge of the applicant, and audition electives.

Internal medicine residency program director perceptions of USMLE Step 1 pass/fail scoring: A cross-sectional survey.

The United States Medical Licensing Examination Step 1 will transition to a pass/fail exam starting no earlier than January 2022. Internal medicine residency programs will need to adapt to these changes. The purpose of this study was to investigate:1. internal medicine residency program directors’ perceptions on the change of Step 1 to a pass/fail exam, and2. the impact on other factors considered for internal medicine residency selection.A validated REDCap survey was sent to 548 program directors at active Accreditation Council for Graduate Medical Education internal medicine residency programs. Contact information from the American Medical Association's Fellowship and Residency Electronic Interactive Database was used.The survey had 123 respondents (22.4%). Most internal medicine program directors do not support the pass/fail change. A greater importance will be placed on Step 2 Clinical Knowledge exam, personal knowledge of the applicant, clerkship grades, and audition electives. Allopathic students from less highly regarded medical schools, as well as osteopathic and international students, will be disadvantaged. About half believe that schools should adopt a graded pre-clinical curriculum (51.2%) and that there should be residency application caps (54.5%).Internal medicine program directors mostly disagree with the pass/fail Step 1 transition. Residency programs will need to reevaluate how applicants are evaluated. Other factors, such as Step 2 Clinical Knowledge score, personal knowledge of the applicant, grades in clerkships, and audition rotations will now be emphasized more heavily.

Race and Gender Bias in Internal Medicine Program Director Letters of Recommendation.

While program director (PD) letters of recommendation (LOR) are subject to bias, especially against those underrepresented in medicine, these letters are one of the most important factors in fellowship selection. Bias manifests in LOR in a number of ways, including biased use of agentic and communal terms, doubt raising language, and description of career trajectory. To reduce bias, specialty organizations have recommended standardized PD LOR. This study examined PD LOR for applicants to a cardiology fellowship program to determine the mechanism of how bias is expressed and whether the 2017 Alliance for Academic Internal Medicine (AAIM) guidelines reduce bias. Fifty-six LOR from applicants selected to interview at a cardiology fellowship during the 2019 and 2020 application cycles were selected using convenience sampling. LOR for underrepresented (Black, Latinx, women) and non-underrepresented applicants were analyzed using directed qualitative content analysis. Two coders used an iteratively refined codebook to code the transcripts. Data were analyzed using outputs from these codes, analytical memos were maintained, and themes summarized. With AAIM guidelines, there appeared to be reduced use of communal language for underrepresented applicants, which may represent less bias. However, in both LOR adherent and not adherent to the guidelines, underrepresented applicants were still more likely to be described using communal language, doubt raising language, and career trajectory bias. PDs used language in a biased way to describe underrepresented applicants in LOR. The AAIM guidelines reduced but did not eliminate this bias. We provide recommendations to PDs and the AAIM on how to continue to work to reduce this bias.

Anticoagulation for Patients With Atrial Fibrillation and End-Stage Renal Disease on Dialysis: A National Survey

Patients with atrial fibrillation (AF) have a significant increased risk of embolic stroke. Patients with end-stage renal disease who are on dialysis have an increased risk of both embolic stroke and bleeding. Stroke-prevention studies with the use of anticoagulation for AF patients have excluded patients on dialysis, so there remains no consensus on their management. We developed and implemented a pan-Canadian multidisciplinary survey to explore the current beliefs and practices concerning patients with AF on dialysis. We developed an online investigator-designed survey with both quantitative and qualitative responses with the use of a secure university-affiliated electronic service. The survey was distributed to physicians via the QxMD platform and directly to internal medicine, cardiology, and nephrology residency program directors for distribution to faculty members. 130 participants responded, including 46 cardiologists, 45 nephrologists, 30 general internists, and 9 other physicians. The preferred anticoagulant was warfarin. The CHADS2 score used to initiate anticoagulation was highly variable, with specialties differing in use of a CHADS2 threshold of ≥ 1 (P < 0.001) and the impact of previous transient ischemic attack/stroke (P = 0.02). Calciphylaxis history affected the decision to prescribe anticoagulation. Specialties differed in thresholds used to consider direct oral anticoagulants for dialysis patients, with nephrologists more likely to prescribe anticoagulation at higher CHADS2 scores. Our survey demonstrated significant heterogeneity of anticoagulation use for stroke prevention in patients with AF on dialysis. Physician specialty and patient risk profiles contributed to the observed variability. This study reemphasises the need for clinical trials, large observational studies, and consensus guidelines to address evident equipoise.